When you are in business you will need to have a system for documentation that will provide accurate files and, at the same time, free up your memory to perform important tasks. Documentation that is done properly will give you accuracy and confidence. Following are some tips to help you with your documentation:
1. DOCUMENT EVERY CONTACT YOU HAVE WITH CLIENTS AND OTHER PROFESSIONALS - It sounds like a lot of work but is not nearly as difficult as trying to remember when you talked with someone-especially if you are to appear in a Court hearing or before a review panel.
2. PREPARE A TEMPLATE THAT IS EASY TO USE FOR ANY TYPE OF CONTACT - The form that I use is multi-purpose and not only has the name(s) of the individual(s) involved, date, time, billing fee and applicable contract, but also has lines on two-thirds of the page for hand-written notes. I keep blank copies on clipboards that are placed in spots around the office so they are easy to access when there is telephone or personal interaction.
3. WRITE LIKE A TEN YEAR OLD WILL BE READING THE NOTES - Make sure that everything you write down is detailed and understandable to others beside yourself. It is amazing how quickly you can forget what happened but having clear and complete notes will help you to remember. Your notes must be written in a simple and clear manner so that anyone could pick up the file and understand details of your contact.
4. WRITE NOTES WITHIN 24 HOURS OF CONTACT - I made a rule for myself several years ago that I would not leave the office at night until all my notes were completed. There are several benefits to doing this including the fact that you can then have an evening without the stress of thinking that there is paperwork piling up for you. Also, if you are called to Court, your diligence will be honoured as most Court recognize the fact that if you write things down within 24 hours, your memory will be more accurate than leaving the notes until later. I once went on vacation and was shocked to return to the office to find that one of the children on my caseload had died while I was away. My file had immediately been taken for investigative purposes and I was so thankful that I had everything in order.
5. FILE YOUR NOTES IMMEDIATELY - When you have piles of papers on your desk, you can experience added stress, whereas a file that is complete and in order will help you to let go and focus on other activities. Filing your notes may only take a few seconds while piling them up may cause hours of work for a later date.
Many therapists state that people are the most important part of the job and leave their paperwork until they are either in trouble with the employer or so totally overwhelmed and disorganized that they have a huge investment of time to put things in order. Paperwork is just as important (or moreso at times) than working with the client. It helps you to keep things in order, have confidence that you have accurate notes of what occurred, and protects you from being a victim of memory loss or being accused of incompetency. Doing your documentation on a daily basis is a habit to be developed which offers huge rewards.